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Wednesday, March 28, 2007

Resource allocation decision-making is not only a pleasurable pastime for bioethicists, it has also serious consequences for real people (yes, people like you and me). In bioethics and health economics academics have been arguing for a long time what criteria are just criteria for determining who is inside, and who will be left to fend for herself outside the life boat. One of the big theoretical arguments has been whether we should aim for the number of life years saved or whether we should aim for the number of lives saved. Crudely put, is it acceptable, in emergency circumstances, to discriminate against the elderly? Should a 90 year old person who has lived most of his or her life be entitled to the same level of (scarce) resources as a 12 year old person? The main, and to my mind, convincing arguments in favour of discriminating in favour of the young person are:

We should try to maximise the number of quality life years with the resources available. There doesn't seem much point in throwing our resources at adding another few months or even a year or two at a 90 year old when with the same resources we could guarantee a teenager to live basically her whole life. [Note: It would be nice, of course, to do both, but the empirical premise of this argument is that we cannot do both due to a lack of resources.]

The second argument seems somewhat related. It's the fair innings argument, suggesting that the 90 year old had his fair shot at life and that he is not entitled to be kept going if that means that a person who hasn't had that fair shot at life would have to forgo living her own good life (eg our teenager).

Well, in the US a policy maker consensus has formed along the lines that these arguments are not good enough and that we should aim for lives saved instead of life years. In the UK the Department of Health has just issued a draft policy document inviting public comments.

This document in the section on 'Fairness' proposes that 'people with an equal chance of benefiting from health or social care resources should have an equal chance of receiving them.' The guidance document was written by a largeish group of mostly substantially beyond the age of 40 luminaries in ethics, theology, public health etc. It's misleadingly labelled an ethics framework when really it's a policy document. As with many such consensus driven documents it's a failure in that it is both vague and minimalistic (I owe this terminology to an insightful paper David Benatar published on another such document in Developing World Bioethics recently.) In the crucial resource allocation case it is sufficiently vague as not to give any guidance at all. The statement can effectively and legitimately be read in two ways, each leading to diametrically opposed practical conclusions.

Firstly, it can be read as saying that an elderly person wouldnot have an equal chance of benefiting from a health resource, given that she wouldn't benefit from survival as long as someone much younger. Ergo it would be acceptable to discriminate in allocation decision making against the elderly.Secondly, it can also be read as saying that an elderly person would have an equal chance of benefiting from a health resource, given that she would survive as a person, as much as someone much younger would survive as a person. Ergo it would be unacceptable to discriminate in allocation decision making against the elderly.

Until we know what the unit is that we are supposed to utilise to measure 'benefit', flipping coins is roughly as useful as this guidance document.

So, we find ourselves in a situation where, regardless of which policy option we prefer, we would and would not be able to identify with what is proposed, subject to how we interpret the fairness related statement above.

This, arguably, renders this policy guideline useless as there would be no uniform policies resulting from it.

We can't even have a decent argument about it as we cannot be certain what it wants to convey... - Makes you wonder about those luminaries and their capacity to produce a guidance document for a crisis situation such as pandemic influenza.